Who should take high blood pressure medicines?

Not everyone who has high blood pressure needs to be treated with drugs some people can control their blood pressure just by adopting healthy lifestyle habits, such as eating heart healthy foods and exercising regularly. However, most people with high blood pressure have to take two or more medications in addition to lifestyle changes to get their blood pressure under control. Medicines to lower high blood pressure ( hypertension) are called antihypertensives. Research suggests that these medications work equally well in men and women.

The goal of therapy with high blood pressure medications is to lower blood pressure and reduce the occurrence of health problems such as heart attack, heart failure, stroke, and kidney damage. Medications that can treat high blood pressure are also used to treat patients with other conditions such as heart attack, heart failure, or kidney disease, even if they have normal blood pressure.

How do blood pressure lowering drugs work?

There are several ways drugs can lower blood pressure, and some medications work in more than one way:

Opening and widening the blood vessels (drugs that work in this way are called vasodilators)

Preventing the blood vessels from narrowing

Reducing the heart’s workload

Reducing the amount of fluid in the body

How do doctors decide which type of medication I should take?

Doctors choose which blood pressure medications to prescribe based on your medical history and other current medical conditions and symptoms.

Some types of high blood pressure medicine lower blood pressure and treat other medical conditions at the same time. Medical conditions that may affect the choice of blood pressure medicine include:

heart failure

previous heart attack

previous stroke

known coronary artery disease (or high risk for it)

diabetes

chronic kidney disease

left ventricular hypertrophy (enlargement of the left pumping chamber of the heart)

Many types of high blood pressure drugs lower blood pressure and reduce the health problems caused by high blood pressure in men and women. Most people with high blood pressure and no other major diseases should be prescribed a thiazide diuretic, either alone combined with an ACE inhibitor, angiotensin receptor blocker, beta blocker, or calcium channel blocker. Large studies have shown that these drugs are best at reducing the risk of heart attack, heart failure, stroke, and kidney disease in men and women. However, everyone responds differently to high blood pressure medications and what worked for most people in a study might not work for you. You may have to try various drugs or combinations of drugs to find the best treatment for you with the fewest side effects.

How long do I have to take my high blood pressure medications?

Blood pressure medications do not cure high blood pressure your blood pressure is only lowered while you are taking the drugs regularly. It will shoot up again once you stop taking them. Since high blood pressure is a risk factor for heart attack and heart disease, you may need to take high blood pressure medications for the rest of your life.

It is important that you adopt a heart-healthy lifestyle such as eating heart-healthy foods and exercising in addition to taking your blood pressure medication regularly. A heart-healthy lifestyle can lower blood pressure as well as several other risk factors for heart disease. Some people can reduce the dosage or the number of medications they are taking after achieving and maintaining normal blood pressure for a year or more. If you haven’t made enough heart-healthy lifestyle changes, this “step-down therapy” may not be possible for you.

ACE Inhibitors

How do ACE inhibitors work?

Angiotensin converting- enzyme (ACE) inhibitors widen blood vessels by blocking the production of angiotensin II, a chemical that causes blood vessels to narrow. The result is that blood requires less force (pressure) to flow through the vessels and the heart doesn’t have to work as hard.

Who should take ACE inhibitors?

ACE inhibitors are often the first choice drugs for treating patients with high blood pressure who also have heart failure or diabetes. This is because ACE inhibitors have other beneficial effects (besides just lowering blood pressure). They can slow the progression of kidney disease in people with high blood pressure and Type 1 diabetes ( insulin-dependent). They may also be used after a heart attack or bypass surgery, or to treat diabetes or kidney disease.

Angiotensin Converting Enzyme (ACE) Inhibitors

Commonly prescribed brands:

Benazepril

Captopril

Lisinopril

Fosinopril

Ramipril

Quinapril

Lotensin

Capoten

Prinivil
Zestril

Monopril

Altace

Accupril

How they are given:

Oral (tablet, capsule, liquid) or IV

What they are used for:

To treat high blood pressure

To treat congestive heart failure when used with diuretic and digitalis medications

To improve survival after a heart attack

You should not be treated with them if:

You have a history of swelling beneath the skin (angioedema) related to previous treatment with ACE inhibitor or of hereditary or unknown origin

Possible side effects:

Dry hacking cough, dizziness, weakness

Pregnancy/nursing:

ACE inhibitors should not be taken during pregnancy or nursing as they are harmful and even fatal to the fetus or baby

What side effects do ACE inhibitors have?

A dry cough is the most common side effect. It occurs in about 12% of patients and is more common in women than men. It is usually not serious, but if it bothers you, your doctor may switch you to another type of medication. The cough goes away almost immediately after you stop taking the ACE inhibitor (talk to your doctor before you stop taking any medication). If you are taking ACE inhibitors, you need to drink plenty of fluids when outside in hot weather or when exercising, since you are more likely to have side effects if you are dehydrated.

The first time you take ACE inhibitors, your blood pressure may drop quickly, and you may feel dizzy or faint. This is known as a “first dose effect.” You may be instructed to take your first dose just before going to sleep so you do not feel its effects.

ARBs : How do angiotensin II receptor blockers work?

Angiotensin II receptor blockers (ARBs) widen blood vessels. They work by blocking the effects of angiotensin II, a chemical that narrows blood vessels. Blood vessels have special receptors for angiotensin II, and when angiotensin II hits them, it causes the blood vessels to narrow. Instead of decreasing the production of angiotensin II (as ACE inhibitors do), ARBs block the blood vessel receptors for this chemical.

Who should take angiotensin II receptor blockers?

ARBs are often used to treat high blood pressure or heart failure and can slow the progression of kidney disease in patients with diabetes. ARBs are a relatively new medicine and it is not yet known if they are as effective as ACE inhibitors. However, they do not cause the dry cough common with ACE inhibitors, so they are often used in patients who cannot tolerate this side effect.

Angiotensin II Receptor Blockers (ARBs)

(check with manufacturer for specific information)

Commonly prescribed brands:

Candesartan

Irbesartan

Losartan

Valsartan

Atacand

Avapro

Cozaar

Diovan

How they are given:

Oral (tablet or capsule)

What they are used for:

To treat high blood pressure

You should not be treated with them if:

You have a history of swelling beneath the skin (angioedema) related to previous treatment with ACE inhibitor

You have swelling beneath the skin of hereditary or unknown origin

You cannot produce urine

Possible side effects:

Upper respiratory tract infection

Dizziness, headache, cough, fatigue

Pregnancy/nursing:

Pregnant women should not take angiotensin II receptor blockers because they can harm the fetus. Women who are nursing should not use these medications; if the treatment is essential, then nursing should be discontinued.

Aldosterone Antagonists

How do aldosterone antagonists work?

Aldosterone is a hormone that causes the body to retain salt and water. Certain cells in the body have special receptors for aldosterone. Aldosterone antagonists block these receptors in the kidneys, heart, blood vessels, and brain. This triggers the body to get rid of more salt and water in the form of urine. This reduces the volume of blood in the body, lowering blood pressure.

Who should take aldosterone antagonists?

Aldosterone antagonists work well at reducing blood pressure in patients with mild to moderate high blood pressure, particularly when combined with ACE inhibitors or ARBs. They may also be useful in treating heart failure after a heart attack.

Older aldosterone blockers (such as spironolactone) also block other hormone receptors that can cause problematic side effects, including lowering of the voice or excessive hair growth in women and men, or enlarged breasts in men. A new class of drugs called selective aldosterone-receptor antagonists (SARAs) block only aldosterone receptors, resulting in fewer side effects. The first of these drugs, eplerenone (Inspra), was approved by the FDA to treat high blood pressure in 2002. Since these drugs are fairly new, it is not yet known which patients benefit the most, so they are usually used only in patients who still have high blood pressure after trying other types of blood pressure drugs.

Aldosterone Antagonists

(check with manufacturer for specific information)

Commonly prescribed brands:

Spironolactone

Eplerenone

Aldactone

Inspra

How they are given:

Oral

What they are used for:

To treat high blood pressure

Swelling ( edema) caused by various conditions, including heart failure

The safety of drugs during nursing is unknown. These drugs can enter a woman’s breast milk, but it is not known if they affect the baby.

What side effects do aldosterone antagonists have?

One possible side effect of aldosterone antagonists is the development of high potassium in the blood ( hyperkalemia), which can have dangerous effects on heart function. If you are on this drug, your doctor will monitor you for this condition. Lowering the dose usually eliminates this side effect.

Alpha Blockers

How do alpha blockers work?

Alpha blockers lower blood pressure by blocking the effects of stress hormones such as adrenaline that can narrow blood vessels. Alpha blockers also slow the heart rate and reduce the force of the heartbeat.

Who should take alpha blockers?

Alpha blockers are not often used in the treatment of high blood pressure because recent evidence shows that using them alone may increase the risk of heart failure. In addition, these drugs are not as effective as other blood pressure medications at reducing the risk of heart attack and stroke. Alpha blockers alone have a small blood pressure lowering effect, so when they are prescribed it is usually in combination with a drug from another class, such as beta blockers (often in a single pill). In men, alpha blockers are mainly useful in patients with an enlarged prostate gland (not cancerous) who also have hypertension, since they can treat both conditions at the same time.

Alpha Blockers, Peripheral & Combinations

Commonly prescribed brands:

Doxazosin

Terazosin

Prazosin

Cardura

Hytrin

Minipress

How they are given:

Oral

What they are used for:

To treat high blood pressure

You should not be treated with them if:

N/A

Possible side effects:

Dizziness, drowsiness, fluid retention

Pregnancy/nursing:

The safety of these medications during pregnancy is unknown

Thiazides (a type of diuretic found in some combination pills, including Minizide) pass across the placenta and can enter a woman’s breast milk

Prazosin can enter a womanâ€™s breast milk

What side effects do alpha blockers have?

Alpha blockers may cause dizziness and fainting, usually after the first dose and in the following days. This side effect is reduced with continued use of the drug.

Beta Blockers

How do beta blockers work?

Beta blockers reduce the workload of the heart by slowing the heart rate and reducing the force of the heartbeat. This reduces the force with which blood is pushed through the blood vessels, lowering blood pressure. Beta blockers also cause the arteries in the legs and arms to narrow, causing less blood to flow through your limbs. This is why some patients who take beta blockers have cold hands and feet, and are generally more sensitive to cold.

Who should take beta blockers?

Beta blockers are used to treat a wide variety of heart conditions in addition to high blood pressure, including chest pain ( angina), heart attack, heart failure, and heart rhythm problems. They are also given to people who undergo bypass surgery. They are usually the first choice drug to treat patients who:

have high blood pressure and stable chest pain

have unstable angina (chest pain that may occur at rest)

have had a heart attack

Beta blockers are often prescribed in combination with ACE inhibitors.

Women who are nursing should not take atenolol. If the treatment is essential, then nursing should be discontinued.

What side effects do beta blockers have?

Since beta blockers can lead to a dangerously slow heartbeat, you will probably be started on a low dose, gradually increasing. The most common side effects of beta blockers are slow heart rate, dizziness, increased tiredness, and sensitivity to cold. As with any medication, do not stop taking it without consulting your doctor. Patients who suddenly stop taking beta blockers could increase their risk of having a heart attack.

Because one of the risks of beta blockers is low heart rate, patients taking them should measure their heart rate periodically. Your doctor will show you how to do this. You should let him or her know if your heart rate is lower than usual or if it is below 50 beats per minute.

Calcium Channel Blockers

How do calcium channel blockers work?

Calcium channel blockers prevent calcium from entering the smooth muscle cells of the heart and blood vessels. Calcium is required for muscles to contract and for the blood vessels to narrow. Calcium channel blockers effectively widen blood vessels and decrease the strength of the heartbeat, causing blood pressure to fall.

Who should take calcium channel blockers?

In addition to treating high blood pressure, calcium channel blockers are also used to treat other heart problems including chest pain ( angina) due to heart disease or coronary spasm (see Prinzmetal’s angina), and some abnormal heart rhythms. For chest pain, calcium channel blockers are often prescribed along with nitrates.

There are two types of calcium channel blockers, and which kind you are prescribed may depend on whether you have certain heart conditions. One type (the dihydropyridines, such as amlodipine and nifedipine) does not slow the heart rate or cause other abnormal heart rhythms (arrhythmias). This type is most often used to treat high blood pressure. The other type (the non-dihydropyridines, such as verapamil and diltiazem) is not recommended in patients who have chronic heart failure or certain types of abnormal heart rhythms (arrhythmias), since they may make these conditions worse. This type of CCB is most often used to treat chest pain.

Many calcium channel blockers come in a short-acting form and a long-acting (sustained release) form. Short-acting calcium channel blockers increase the risk of heart attack and stroke when used over an extended period and are therefore no longer used to treat high blood pressure.

A large study of women aged 50 to 79 with high blood pressure but no history of heart disease had a higher risk of heart-related death when given combination therapy with a diuretic and CCB than with a diuretic and a beta blocker. Women treated with a CCB alone had a higher risk of heart-related death than women treated with a diuretic alone. Because of these findings, calcium channel blockers are not the drug of choice for lowering blood pressure in older women.

Calcium Channel Blockers

Commonly prescribed brands

Amlodipine

Diltiazem

Nifedipine

Verapamil

Felodipine

Norvasc

Tiazac

Procardia

Covera-HS

Plendil

How they are given

Oral (tablet or capsule)

What they are used for

To treat high blood pressure

To treat chest pain

To treat chest pain due to a spasm

You should not be treated with them if

You have been diagnosed with:

Abnormally low heart rate

Second- or third-degree heart block (a delayed or complete lack of electrical communication between the upper chambers of the heart and the lower chambers of the heart) unless you have a pacemaker

Low blood pressure

Possible side effects

Headaches and swelling of the ankles

Verapamil can cause constipation and excessive slowing of the heartbeat

Pregnancy/nursing

The safety of these medications during pregnancy is unknown

Women who are nursing should not use calcium channel blockers; if the treatment is essential, then nursing should be discontinued

What are the possible side effects and risks of calcium channel blockers?

The most common side effects of calcium channel blockers are a brief headache (that usually fades over time), edema (swelling) in the legs, constipation, fatigue, and stomach irritation. Some early studies found that calcium channel blockers could increase the risk of many types of cancer including breast and uterine cancer, but later studies showed that this is most likely not true.

Diuretics : How do diuretics work?

Diuretics (sometimes called water pills) reduce the amount of fluid in the body by stimulating your kidneys to get rid of excess water and salt as urine. This lowers the amount of blood in the blood vessels, which in turn lowers blood pressure. Diuretics are also used to treat heart failure and kidney disease.

There are three types of diuretics used in the treatment of high blood pressure:

Loop diuretics work by making the kidneys get rid of more sodium and potassium than normal. When these substances leave the body as urine, water goes along with them. Of all the types of diuretics, these produce the greatest increase in urine flow.

Thiazide diuretics cause more salt to be excreted than other diuretics, and are the most commonly used diuretic to treat high blood pressure.

Potassium-sparing diuretics are less powerful at getting rid of water and lowering blood pressure than other types of diuretics, but they have the advantage of preventing your body from losing too much potassium (see below). They are often prescribed with another type of diuretic to treat high blood pressure.

Who should take diuretics?

Diuretics are the best initial drug for most men and women with high blood pressure.3Thiazide diuretics are usually used first because they tend to have fewer side effects than other types of diuretics. Since most patients require two or more drugs to control hypertension, diuretics are often combined with other blood pressure lowering drugs such as ACE inhibitors, ARBs, beta blockers, and calcium channel blockers.

What are the possible side effects of diuretics?

Diuretics cause you to lose more than just salt and water – other substances including potassium, calcium, and magnesium are also flushed out. Your doctor may prescribe supplements to replenish this loss, or advise you to alter your diet (for example, eat more foods high in potassium, such as bananas). One of the most common side effects of diuretics (other than potassium-sparing diuretics) is potassium loss. Some patients may experience sensitivity to sunlight while taking diuretics, so they are advised to wear sunscreen and avoid tanning booths. Other common side effects of diuretics include frequent urination (which may last for up to 6 hours after a dose) and dehydration.

The safety of these medications during pregnancy is unknown; thiazides can cause some problems in infants, but no birth defects have been reported

The safety of thiazide diuretics during nursing is unknown. They can enter a woman’s breast milk.

Potassium-Sparing Diuretics

Commonly prescribed brands

Amiloride

Triamterene

Midamor

Dyrenium

How they are given

Oral

What they are used for

To treat high blood pressure and congestive heart failure. They are usually combined with thiazide or other diuretics to help restore normal potassium levels and prevent abnormally low potassium levels in the blood ( hypokalemia).

You should not be treated with them if

You are taking other medication to maintain normal potassium levels

You have been diagnosed with kidney or liver problems

You have kidney disease as a result of diabetes

You are unable to produce urine

You have a high potassium level in your blood

Possible side effects

Increased level of potassium in the blood (which can cause weakness, numbness, confusion, and heaviness in the legs)

Pregnancy/nursing

The safety of these medications during pregnancy and nursing is unknown

Combination Diuretics

Commonly prescribed brands

Amiloride & hydrochlorothiazide

Triamterene & hydrochlorothiazide

Moduretic

Dyazide/
Maxzide

How they are given

Oral

What they are used for

To treat high blood pressure or swelling (edema), and some cases of chronic heart failure, in patients who cannot take thiazide diuretics alone because of concerns about low potassium (for example, patients with heart rhythm problems)

You should not be treated with them if

You are taking another medication to maintain a normal potassium level (such as potassium supplements, spironolactone, amiloride, triamterene)

You are unable to produce urine

You have been diagnosed with kidney problems

You have kidney disease as a result of diabetes

Possible side effects

Increased level of potassium in the blood (which can cause weakness, numbness, confusion, and heaviness in the legs)

Pregnancy/nursing

The safety of these medications during pregnancy is unknown

The safety of these medications during nursing is unknown, but components of these drugs can enter a woman’s breast milk

Central Acting Drugs

How do central acting drugs work?

These drugs lower blood pressure by acting in the brain and central nervous system. They reduce the number of nerve signals telling the blood vessels to narrow, thus relaxing the arteries in the legs and arms.

Who should take central acting drugs?

Central acting drugs are not usually the first choice for treating high blood pressure since they do not lower blood pressure as well as other types of medicines and are more likely to have side effects. They are only used after other types of drugs have failed to control a person’s blood pressure.

Central Acting Drugs

Commonly prescribed brands

Clonidine

Methyldopa

Methyldopa chlorothiazide

Methyldopa hydrochlorothiazide

Catapres TTS
Catapres

Aldomet

Aldoclor

Aldoril

How they are given

A skin patch or orally (pill)

What they are used for

To treat high blood pressure

You should not be treated with them if

You should not take methyldopa if you have active liver disease or a liver disorder previously associated with methyldopa therapy; you cannot produce urine; or if you are on MAO inhibitors, a type of antidepressant

Possible side effects

Dizziness, drowsiness, dry mouth, anxiety, depression

Pregnancy/nursing

Methylodopa is generally considered safe to use during pregnancy; thiazides may cause some problems in infants but can be used if they are clearly needed

The safety of clonidine during pregnancy is unknown

The safety of these drugs during nursing is unknown, but it is known that they can enter a woman’s breast milk

What are the possible side effects of central acting drugs?

The most common side effects include dryness of the mouth and fatigue. Some patients cannot stand these side effects and may have to switch to another drug.

Direct Vasodilators : How do direct vasodilators work?

Blood pressure drugs that widen blood vessels are called vasodilators. Direct vasodilators act directly on the smooth muscle in the walls of your blood vessels, causing them to widen. Examples include hydralazine (Apresoline) and minoxidil (Loniten).

Who should take direct vasodilators?

Because they often cause side effects, direct vasodilators are usually used only after several types of other drugs combined have failed to control your blood pressure.

Pericardial effusion (fluid buildup around the heart that may prevent it from pumping properly)

Increased heart rate

Pregnancy/nursing

The safety of these drugs during pregnancy is unknown

Minoxidil should not be used while nursing. The safety of hydralazine during nursing is unknown.

What are the possible side effects of direct vasodilators?

Direct vasodilators can cause a dangerous increase in heart rate, fluid retention, and swelling ( edema). They usually must be combined with a beta blocker or the central acting drug clonidine to prevent these side effects. Another common side effect of minoxidil is excessive hair growth all over the body (it’s found in the hair loss treatment Rogaine).

Combined Medicines

Most people need to take two or more blood pressure drugs to control their blood pressure. If one type of medication is not enough, your doctor may prescribe combination therapy with two or more types of antihypertensive medication. This allows for lower doses of each individual drug, reducing the risk or severity of side effects. Some combinations are available together in a single pill.

Combined Alpha Blockers & Beta Blockers

Commonly prescribed brands

Carvedilol

Labetalol

Coreg

Normodyne

How they are given

Oral

What they are used for

To treat high blood pressure

You should not be treated with them if

You have been diagnosed with:

Second- or third- degree heart block (a delayed or complete lack of electrical communication between the upper chambers of the heart and the lower chambers of the heart)

Diabetes, Race and Pregnancy

Are there special considerations for women who have diabetes?

The risk of death due to heart disease is 3 to 6 times higher for women with diabetes than women without diabetes. Most people with diabetes also have high blood pressure. It is especially important to control your blood pressure if you have diabetes. Research shows that diabetics are less likely to die or have a heart attack if their blood pressure is 130/80 mm Hg or less — a little lower than the target for people without diabetes (140/90 mm Hg).

Diuretics, beta blockers, ACE inhibitors, ARBs, and calcium channel blockers have all been shown to reduce the risk of heart disease and stroke in diabetics. ACE inhibitors and ARBs have added kidney-protecting benefits, which are particularly important for people with diabetes. However, no single drug class is clearly better than the others – getting your blood pressure under control is more important than taking a specific drug for its kidney-protecting benefits.

People with diabetes taking high blood pressure medicines may need to monitor their blood sugar more often than normal. Diuretics increase the risk of high blood sugar (hyperglycemia), and beta blockers may hide symptoms of low blood sugar (hypoglycemia).

Are there special considerations for African-American women?

When used alone, beta blockers, ACE inhibitors, and ARBs are all less effective at lowering blood pressure in African Americans than in white people. African Americans taking ACE inhibitors are also more likely to experience a dry cough and other side effects than white patients. Thiazide diuretics and calcium channel blockers work equally well in both races. When beta blockers, ACE inhibitors, or ARBs are combined with a diuretic, their combination is just as effective in African Americans and whites. The most important thing is to get your blood pressure under control, and this may mean trying a number of different medications. You should not avoid specific types of medications based on your race.

Is it okay to take high blood pressure medications during pregnancy?

There are two major kinds of high blood pressure that can affect pregnancy.

A woman who already has high blood pressure may become pregnant. If she has severe high blood pressure, she may benefit from drug treatment during pregnancy. It is less clear if drug treatment of mild high blood pressure during pregnancy is any better than no therapy at all. If you are pregnant or planning to become pregnant, tell your doctor so your medication can be properly adjusted or slowly phased out before pregnancy.

There are also high blood pressure disorders that first develop during pregnancy (gestational hypertension) : either a short-term rise in blood pressure that starts in mid-pregnancy and goes away after birth (transient hypertension of pregnancy), or high blood pressure that is a symptom of a more serious syndrome called preeclampsia. In women with these types of high blood pressure, treatment with high blood pressure drugs is not beneficial unless blood pressure is dangerously high (above 160/100 mm Hg).